Background In 2010, the NCEPOD¹ report demonstrated a lack of good nutritional care for preterm infants. Since that time various approaches have evolved including standardisation of PN,² concentrated standardised PN³ and publication of a national framework from BAPM.⁴ The delivery of nutrition to preterm infants on our unit has been continuously monitored, evaluated and adapted.

Aims The aim of this audit was to evaluate whether reformulating our PN recipes would improve nutritional intake and thus growth parameters over the first 14 days after birth.

Methods Data was collected from our EPMA system and analysed retrospectively from all infants born at our unit <28 weeks gestation or <1Kg from 16/4/2016 to 15/4/2017 (audit 1) and from 1/6/2018 to 31/5/2019 (audit 2).

Results Data from a total of 33 patients was analysed using Excel™. The mean gestation and weight were similar for both audit cycles. Audit 1: gestation 26.5 weeks, weight 0.75 kg; audit 2: gestation 26.7 weeks, weight 0.74 kg. The average time from birth to PN was less in audit 2 (12 hrs 8 mins vs 13 hrs 12 mins), however the time from PN being prescribed to being administered took over 3 times longer (5 hrs 1 min vs 1 hr 30 mins). No patient received PN within 6 hours of birth in audit 2 compared to 20% in audit 1. The average nitrogen intake was higher in audit 2 than audit 1 (0.41 g/kg/day vs 0.36 g/kg/day) and the highest protein intake increased from 0.55 g/kg/day to 0.69 g/kg/day respectively; the average energy intake decreased from 73.5 kcal/kg/day in audit 1 to 68 kcal/kg/day in audit 2. The non-nitrogen energy to nitrogen ratio was lower in audit 2 versus audit 1 (165.3 kcal/g nitrogen vs 204.7 kcal/g nitrogen). There was no change in the percentage of patients requiring insulin: 40%. More patients had started receiving lipid infusion in the first 2 days after birth in audit 2 compared to audit 1 (94% compared to 33%). Both audits had 2 patients that had still not reached their birth weight by day 14, however the patients in audit 2 gained on average 9.12 g/kg/day compared to 4.96 g/kg/day in audit 1.

Conclusion Reformulating the PN resulted in higher nitrogen intakes and higher weight gain by day 14, although the full benefit may not have been achieved due to the lower kcal intake and non-nitrogen energy to nitrogen ratio. The time from birth to PN and the time taken to administer PN once prescribed were longer so work needs to be done on addressing these issues and reducing barriers to nutrition. The total nitrogen intake with PN and EN also needs to be reviewed to prevent excessive nitrogen intake which may result if enteral feeds increase and the rate of PN is maintained.

References

1. Stewart JAD, Mason DG, Smith N, Protopapa K, Mason N, on behalf of CEPOD. 2010. A mixed bag; an enquiry into the care of hospital patients receiving parenteral. https://www.ncepod.org.uk/2010report1/downloads/PN_report.pdf Accessed 03/07/2019

2. Paediatric Chief Pharmacists Group. Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates and Children. 2011

3. Morgan C, Radbone L, Birch J. 2016 The Neonatal Parenteral Nutrition (PN) QIPP Toolkit https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/documents/documents/national-toolkit-for-standardising-pn Accessed 03/07/2019

4. British Association of Perinatal Medicine. The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. 2016. https://www.bapm.org/sites/default/files/files/Parenteral%20Nutrition%20April%202016.pdf Accessed 03/07/2019